Academic Health Centers Embrace Alternative Medicine

Academic health centers are increasingly willing to embrace, rather than rebuff, complementary and alternative medicine (CAM) therapies. Indeed, in the last few years, "integrative" and "complementary" centers or programs have sprung up at dozens of academic health centers, and the trend will likely continue. But the frequency with which these newfound coalitions have taken place by no means implies that the melding of "conventional" and "alternative" medicines will be effortless. At a mid-November meeting in Philadelphia sponsored by the University of Pennsylvania School of Medicine, Penn's Center for Bioethics, and the National Institutes of Health Center for Complementary and Alternative Medicine, 100 physicians, researchers, and ethicists came together to discuss the implications of incorporating complementary and alternative medicine into established academic health centers. Alfred P. Fishman "Most institutions now, especially those that deal with women's health, aging, and cancer, feel a great pressure to provide unconventional therapies which will bring comfort and improve the quality of life for their patients," explains Alfred P. Fishman, the William Maul Measey Professor of Medicine emeritus and senior associate dean for program development at the University of Pennsylvania School of Medicine. At the meeting, along with Fishman, who was a conference organizer and moderator, were Marcia Angell, executive editor of the New England Journal of Medicine; David Eisenberg, director of the Center for Alternative Medicine Research and Education at Harvard Medical School's Beth Israel Deaconess Medical Center; George Lundberg, editor in chief of Medscape; and Arnold S. Relman, professor emeritus of medicine and social medicine at Harvard Medical School. According to Fishman, despite the big names, the conference was kept small to encourage widespread discussion. The trend to integrate, says Fishman, started with physicians' and other health professionals' attempts to satisfy demand from patients. The creation of the NIH Center for Complementary and Alternative medicine and NIH funding followed. But with little real basic or clinical research on these unconventional therapies, academic health centers, wary of supporting unproven treatments, elected to set up centers focusing on research and education. Thus far, few academic centers have created "official" clinical centers. In a session on current integrative health center models, Eisenberg recounted the evolution of his own center, which was launched in 1995. "I was explicitly told that we are not ready, the field is not mature, and [that we should] try to create standards in research and education," he said. But about a year ago, his directives changed. Harvard hospital CEOs started getting interested in providing clinical services. Eisenberg cited his program's successes thus far: publications on CAM research, CAM medical school courses, CAM fellowships, and some progress on issues of malpractice insurance. He's also encouraged by renewed interest from Harvard's basic science researchers. "Scientists are increasingly interested in the basic questions, the mechanistic questions, the phenomenological questions," says Eisenberg. "And they're now approaching us saying 'let's work with you.'" Fishman adds that because patients seeking complementary medicine are often seeking relief from pain (through techniques such as acupuncture, for example), research into the mechanisms underlying pain is especially important. Other speakers, including Larry Burk, Duke University's director of integrative medicine education, echoed Eisenberg's comments. Burk also noted the establishment of a consortium of academic health centers--at places such as the University of Arizona, the University of Minnesota, and the University of Maryland--that have integrative medicine programs. Failures to date include a lack of any real CAM clinics within academic health centers, unreliable credentialing, and an unwillingness or inability of doctors already strapped for time to learn about CAM therapies that haven't been taught in medical school. According to Fishman, Penn's recently initiated program addresses some of these problems. The approach could get to potential CAM patients faster, and circumvent the therapy roadblocks presented by an actual center by setting up what Fishman calls a "virtual" center. "Instead of building a theatre where we'd house all these sorts of complementary therapies ... we're concentrating them where they can be of most help," he claims. He and William N. Kelley, Penn Health System CEO and dean of Penn's School of Medicine, decided that the way to approach CAM therapies is to not let the practice trickle in from the periphery, but to examine it overtly and ask where these treatments fit into the existing fabric of an academic medical center. In early 1998, Kelley set up a working group made up of both strong CAM advocates and "hard-nosed" scientists; they discussed where and how unconventional therapies might fit into already established sectors of Penn's health center. Anybody who wants to introduce a new therapy goes through a set pathway: A steering committee of experts in that particular area evaluates the therapy and any available related research. "We don't want a system of practice that's different from Western medicine," says Fishman. "It's not alternative ... we use them as complementary therapies and evaluate each modality using conventional criteria." But all academic health centers have yet to resolve important ethical questions as they get closer to offering clinical CAM services. Is it ethical, for example, to recommend or voice disapproval about a CAM therapy you know little about in terms of relative risk or value? Is it ethical not to? As Eisenberg pointed out at the meeting, only a small fraction of CAM therapies have been subjected to sufficient credible research to provide evidence of safety, efficacy, or lack thereof. A future conference, suggested Eisenberg, should be with leaders of institutional review boards (IRBs) and pharmacy and therapeutics committees. "This is where the buck stops," he said. "These are the ones that have the power to determine will this therapy be allowed and if so under what circumstances, by whom, according to what criteria and what credentials." Fishman, though, contends that the problem isn't necessarily with IRBs' standards, but with the lack of reliable CAM research that those committees can use to evaluate proposed therapies critically. Eugene Russo can be contacted at erusso@the-scientist.com.

Academic Health Centers Embrace Alternative Medicine

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